Emergency neurology, neurocritical care, and ethics/patient safety
This domain tests structured resuscitation, recognition of neurological deterioration, prognostication after brain injury, and the ethical framework for decisions near the end of life.
Coma and raised intracranial pressure
Assess airway, breathing, circulation, glucose, pupils and GCS (E4 V5 M6; intubated patients are scored V1 and this must be stated). Brainstem reflexes localise: asymmetric pupils suggest uncal herniation; fixed dilated pupils with absent corneals suggest severe brainstem injury. Raised pressure is managed with head elevation to 30 degrees, normocapnia (PaCO2 35-40 mmHg), sedation, analgesia, osmotherapy (mannitol 0.25-1 g/kg or hypertonic saline), seizure control, and decompressive craniectomy for malignant middle cerebral artery infarction in suitable patients.
Neurocritical care
Status epilepticus follows the benzodiazepine-second line-anaesthesia escalation. Neuromuscular respiratory failure requires monitoring of forced vital capacity (intubate around 20 mL/kg or below or falling rapidly), negative inspiratory force, and bulbar function - in Guillain-Barré and myasthenic crisis. After cardiac arrest, targeted temperature management, avoidance of hyperthermia, and delayed prognostication at 72 hours or later matter: absent pupillary and corneal reflexes, absent bilateral N20 somatosensory responses, and status myoclonus support poor outcome, but sedation and hypothermia must be excluded first. Subarachnoid haemorrhage requires nimodipine, blood pressure control, and monitoring for hydrocephalus and vasospasm.
Ethics and patient safety
Assess capacity using four elements: understanding, retaining, weighing the information, and communicating a choice. Treat in an emergency under the doctrine of necessity when capacity is absent and delay is dangerous, and involve family and advocates. Informed consent covers risks, benefits, alternatives, and the right to refuse. Brain death requires a known cause, exclusion of reversible factors (sedation, hypothermia, metabolic disturbance), and formal clinical testing with an apnoea test. Do-not-attempt-resuscitation decisions and withdrawal of life-sustaining treatment are made in the patient's best interests and documented. Patient safety priorities include anticoagulation errors, missed time-critical diagnoses, medication reconciliation, handover (SBAR), falls prevention, and open disclosure of harm.
Worked example
An intubated patient after cardiac arrest is sedated and cooled. On day 1 the family asks about prognosis. The correct answer: prognostication is deferred until at least 72 hours after return of circulation and after sedation has been cleared, using clinical examination, somatosensory evoked potentials and EEG. Earlier predictions are unreliable and potentially self-fulfilling.
Traps
A low GCS in a sedated patient does not indicate brain death. Do not prognosticate during hypothermia or sedation. Locked-in syndrome retains consciousness despite apparent unresponsiveness. Alcohol and drugs mimic brain death. Document capacity assessments and best-interest decisions; undocumented reasoning is a common source of criticism.